Failure to Complete Significant Change MDS for Suicidal Ideation
Summary
The facility failed to complete a comprehensive MDS significant change assessment within 14 days after it determined, or should have determined, that Resident #2 had a significant change in mental condition. Resident #2 was a male resident with a history of stroke, hypertension, BPH, diabetes mellitus, hyperlipidemia, thyroid disorder, and aphasia. His admission MDS showed a BIMS score of 14 with no reported depressed mood, and a later quarterly MDS showed a BIMS score of 12 with the same mood interview responses coded as not depressed or lacking interest. Record review showed repeated suicidal ideation and related behavioral events beginning with a nurse progress note documenting that the resident told the IDT he planned suicide by jumping out a window, wrapping cords around his neck, and rolling out of bed. He was sent to the ER for suicidal ideation. Additional notes documented further suicidal statements and emergency evaluations, including a psychiatric referral, another episode where he told a psychiatrist he wanted to kill himself and was sent to a psychiatric hospital, another event where 911 was called after he said he wanted to kill himself, and a later event where he called 911 and stated he planned to kill himself at 6 p.m. that day. The resident’s care plan reflected suicidal thoughts and ongoing suicidal ideations, but the MDS assessments reviewed did not reflect the change in mental condition. The DON stated the resident had been suicidal since admission and confirmed multiple suicidal statements and hospital transfers, while the MDS staff stated they were responsible for accurate assessments and that the assessments should reflect the care provided. The Administrator stated there was nowhere to put suicidal ideation on the MDS mood section and said the care plans were based on the MDS data. The facility policy stated the IDT was to follow RAI guidelines for MDS processes and use the RAI manual to support coding and other MDS procedures.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Complete Significant Change MDS Assessment: A resident with dementia, progressive neurological conditions, and seizure disorder had an admission MDS that coded no mobility device use and independence with ADLs, but later was observed ambulating with a walker and gait belt. Quarterly MDSs still did not code walker use and showed increased ADL assistance needs, yet no comprehensive or significant change MDS had been completed. MDS coordinators said they were unaware of the walker use, believed the resident likely should not have been coded as independent, and confirmed the significant change MDS was missed.
The facility failed to complete a Significant Change MDS within the required timeframe for a resident with diabetes and COPD who was admitted to hospice. The MDS Coordinator acknowledged that the assessment was completed after the 14-day deadline.
The facility failed to complete an MDS SCSA within the required timeframe after a resident elected hospice. The resident’s hospice services began and the SCSA was completed late, and the MDS Coordinator acknowledged the assessment was probably completed after the 14-day window. CMS RAI guidance requires a SCSA when a terminally ill resident enrolls in hospice and remains in the facility.
The facility failed to complete SCSA MDS assessments within 14 days for two residents after fractures were identified. One resident with dementia, osteoporosis, AFib, HTN, and depression had a right fibular fracture after a foot/ankle injury, and another resident with dementia, TIA history, stroke history, hypothyroidism, and bilateral above-the-knee amputations had a left elbow fracture. The DON could not provide a policy or documentation for when and how a significant change assessment is completed, and the DON and an LPN confirmed the assessments were not done.
Delayed Significant Change Assessment for Hospice Election: A resident with cancer elected hospice, but the facility did not complete the SCSA within the required 14-calendar-day timeframe. The MDSC stated she did not know the assessment had to be completed within 14 days, and the DON believed they had 2 weeks to complete a significant change for hospice. The facility policy listed the MDS completion date as the 14th calendar day after determination of significant change in status.
Failure to complete timely significant change assessment: A resident with Alzheimer's disease, stroke, DM2, dysphagia, depression, heart disease, and dementia with agitation had a 5.15% weight loss in one week and developed a stage III pressure ulcer on the bilateral buttocks after an MDS showed no significant weight change and no unhealed pressure ulcers. The ADON stated she was unaware of any IDT discussions about whether a Significant Change MDS should have been completed before hospice was initiated.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a significant change MDS assessment for a resident with a history of progressive neurological conditions, non-Alzheimer's dementia, and seizure disorder or epilepsy. The admission MDS showed a BIMS score of 8 out of 15, no upper or lower range of motion impairment, no use of mobility devices, and independence or set-up/clean-up help only for all ADLs. However, observation later showed the resident ambulating with a walker and wearing a gait belt, which differed from the admission assessment and from subsequent quarterly MDS assessments. The quarterly MDS assessments also did not code the resident as using a walker and showed increased assistance needs, including partial/moderate assistance with oral hygiene, personal hygiene, showering/bathing, and toileting hygiene, as well as supervision or touching assistance with some other ADLs. Review of the completed MDS assessments showed no comprehensive MDS, including a significant change assessment, had been completed since admission. MDS coordinators stated they were not aware the resident was using a walker, believed the resident probably should not have been coded as independent for ADLs on the admission MDS, and confirmed that a significant change MDS should have been completed but had not been.
Delayed Significant Change MDS Completion
Penalty
Summary
The facility failed to complete a Significant Change MDS within the required timeframe for Resident 2, who was admitted in 1/2026 with diagnoses including diabetes and chronic obstructive pulmonary disorder. An Election of Benefits and Informed Consent document showed the resident was admitted to hospice services on 5/24/26, but the Significant Change MDS was not completed until 6/18/26, which was 11 days after the required 14-day timeframe. On 7/22/26 at 12:27 PM, Staff 8, the MDS Coordinator, acknowledged that the Significant Change MDS completion date exceeded the required timeframe.
Late MDS SCSA After Hospice Election
Penalty
Summary
The facility failed to complete a Minimum Data Set (MDS) Significant Change in Status Assessment (SCSA) within 14 days of a resident’s hospice election for Resident #30, who was receiving hospice services. Resident #30’s hospice certification and plan of care documented that hospice care services started on 12/31/25, and the resident’s SCSA MDS documented hospice services. The MDS Summary Page showed the 1/6/26 SCSA MDS was completed on 1/15/26. During interview, the MDS Coordinator stated that a SCSA has to be completed within 14 days of admission to hospice, including the day of admission, and acknowledged that she missed it and probably completed it late. The CMS LTC RAI User Manual states that a SCSA is required when a terminally ill resident enrolls in hospice and remains a resident in the nursing home, and that it must be completed within 14 calendar days after the determination that a significant change in status has occurred.
Failure to Complete Significant Change Assessments After Fractures
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS within 14 days for two residents after changes in condition. Resident 2 was admitted with diagnoses including osteoporosis, dementia with psychotic disturbance, depression, atrial fibrillation, hypertension, and dizziness/giddiness. Progress notes dated 6/30/26 documented an injury to the resident’s right foot/ankle, and x-ray findings showed a right fibular fracture. The record review showed no SCSA MDS completed within 14 days of that fracture. Resident 3 was admitted with diagnoses including mental disorders due to known physiological conditions, transient ischemic attack, cerebral infarction without residual deficits, hypothyroidism, bilateral above-the-knee amputations, and dementia. Progress notes dated 12/1/25 documented an x-ray revealing a fracture to the left elbow. The clinical documentation showed no significant change assessment completed within 14 days of that change in condition. The DON was unable to provide a policy or documentation on when and how a significant change is to be done on an MDS, and an interview with the DON and an LPN confirmed that the SCSA MDS was not completed after either resident’s fracture and should have been done.
Delayed Significant Change Assessment for Hospice Election
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) through the Resident Assessment Instrument (RAI) process within the required time frame for a resident who elected hospice benefits. Resident #11, who had diagnoses including cancer, was admitted to hospice effective 2/20/26. The resident’s MDS showed that the SCSA dated 3/4/26 was completed on 3/10/26, which was not within 14 calendar days of the hospice election and should have been completed by 3/6/26. During the survey, the resident was observed in a wheelchair and stated that hospice was going well. The MDS Coordinator stated that a significant change for hospice should be done within 14 days of going on hospice and acknowledged that this resident’s MDS was dated 3/4/26, but said she did not know it had to be completed within 14 days. The DON stated she believed they had 2 weeks to complete a significant change for hospice, and the Regional LNHA stated the MDSC misinterpreted the guidelines for opening an MDS versus completion of the MDS. The facility policy titled MDS Completion and Submission Timeframes stated the MDS completion date as the 14th calendar day after determination of significant change in status.
Failure to Complete Timely Significant Change Assessment
Penalty
Summary
The facility failed to timely complete a significant change assessment for a resident who experienced a major decline in status after a severe weight loss and the development of pressure ulcers. Resident #50 had diagnoses including Alzheimer's disease, stroke, type two diabetes, difficulty swallowing, depression, heart disease, and dementia with agitation. An admission/Medicare 5-day MDS assessment showed the resident was severely cognitively impaired, with no or unknown significant weight changes and no unhealed pressure ulcers at that time. The resident's record later showed a weight of 203.9 pounds on 05/19/26 and 193.4 pounds on 05/26/26, a 5.15% loss in one week. A weekly wound observation dated 05/25/26 documented that the resident had acquired a stage III pressure ulcer on bilateral buttocks. The Facility RAI 3.0 User's Manual states a significant change assessment should be completed by the 14th calendar day after the facility determined the change occurred. During interview, the ADON stated she was unaware of any IDT discussions to determine whether a Significant Change MDS should have been completed prior to initiation of hospice in July 2026.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.